Self-treatment of benign paroxysmal positional vertigo
Semont maneuver vs Epley procedure
A. Radtke, MD,
M. von Brevern, MD,
K. Tiel-Wilck, MD,
A. Mainz-Perchalla, MD,
H. Neuhauser, MD MPH and
T. Lempert, MD
From the Neurologische Klinik der Charité, Campus Virchow Klinikum, Berlin, Germany.
Address correspondence and reprint requests to Dr. Andrea Radtke, Neurologische Klinik der Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany; e-mail: andrea.radtke{at}charite.de
The authors compared the efficacy of a self-applied modifiedSemont maneuver (MSM) with self-treatment with a modified Epleyprocedure (MEP) in 70 patients with posterior canal benign paroxysmalpositional vertigo. The response rate after 1 week, definedas absence of positional vertigo and torsional/upbeating nystagmuson positional testing, was 95% in the MEP group (n = 37) vs58% in the MSM group (n = 33; p < 0.001). Treatment failurewas related to incorrect performance of the maneuver in theMSM group, whereas treatment-related side effects did not differsignificantly between the groups.
Posterior canal benign paroxysmal positional vertigo (PC-BPPV)is caused by dislodged otoconia that move within the PC wheneverhead position is changed. The resulting endolymph flow activateshair cell receptors, causing short-lasting vertigo and a mixedtorsional/upbeating nystagmus. This "canalolithiasis" hypothesishas been corroborated by the success of therapist-guided positioningmaneuvers that aim to clear the PC of trapped particles. Incontrolled trials, single applications of the Epley procedure1or the Semont maneuver2 relieved 70 to 90% of patients.3-5 However,this indicates that some patients require repeated treatmentuntil positional vertigo resolves completely. Therefore, complementaryself-treatment is a desirable option to abort BPPV. We recentlyshowed that self-treatment with a modified Epley procedure (MEP)relieved 64% of 28 patients within 1 week, whereas the Semontmaneuver has not yet been evaluated for self-treatment.6 Therefore,we compared the efficacy of self-treatment with a modified Semontmaneuver (MSM) and the MEP.
Forty-one outpatients with unilateral PC-BPPV from a dizzinessclinic and 29 patients from a neurologist’s practice wereincluded according to the following criteria:
History of short-lasting (<1 minute) rotational vertigo precipitatedby changes of head position;
A mixed torsional/upbeating nystagmusbeating toward the undermostear elicited by positional testingin the lateral or head-hangingposition for <60 seconds7as observed with Frenzel glasses;and
Reversal of torsionalnystagmus on sitting up.
Patients who had received any positioning maneuver during theacute episode of BPPV, patients with bilateral or horizontalcanal BPPV, and patients who could not reliably perform self-treatmentbecause of language problems or lack of mobility were excluded.
Seventy-nine patients were eligible. After giving informed consentaccording to the local ethics committee, patients were randomlyassigned to apply MEP (n = 42) or MSM (n = 37). Five patientsin the MEP group and four in the MSM group were lost to follow-up.Seven of these nine patients did not return for positional testing,and two did not complete the exercise because of concurrentcardiac arrhythmia or a sore hip. Therefore, statistical analysiswas performed on 70 patients (10 men, 60 women; age, 35 to 80years [mean, 60 ± 12 years]). The median duration ofacute BPPV was 8 weeks. BPPV was idiopathic in 55 patients oroccurred after head trauma (n = 4) or vestibular disease (n= 11). Age, sex, and mean duration of the acute episode didnot differ significantly between the two groups.
All patients received an illustrated instruction with theirspecific exercise for the affected ear (figure 1). The sequenceof head and body movements was explained. Patients then performedthe maneuver once under supervision of the instructing physician.Patients performed the exercise three times daily until positionalvertigo had ceased for at least 24 hours. They indicated ina diary whether positional vertigo occurred during each treatmentsession to determine the number of sessions needed for subjectiverelief of vertigo and documented treatment-related side effects(e.g., nausea, gait imbalance, and dizziness). Successful treatmentafter 1 week was defined as absence of positional vertigo andabsence of nystagmus on positional testing. Patients were askedto perform the maneuver again on their second visit to assessaccuracy of treatment execution.
Figure 1. (A) Instructions for the modified Epley procedure (MEP) for left ear posterior canal benign paroxysmal positional vertigo (PC-BPPV). For right ear BPPV, the procedure has to be performed in the opposite direction, starting with the head turned to the right side. 1. Start by sitting on a bed with your head turned 45° to the left. Place a pillow behind you so that on lying back it will be under your shoulders. 2. Lie back quickly with shoulders on the pillow, neck extended, and head resting on the bed. In this position, the affected (left) ear is underneath. Wait for 30 secondS. 3. Turn your head 90° to the right (without raising it), and wait again for 30 seconds. 4. Turn your body and head another 90° to the right, and wait for another 30 seconds. 5. Sit up on the right side. This maneuver should be performed three times a day. Repeat this daily until you are free from positional vertigo for 24 hours. (B) Instructions for the modified Semont maneuver (MSM) for left ear PC-BPPV. For right ear BPPV, the maneuver has to be performed in the opposite direction, starting with the head turned toward the left ear. 1. Sit upright on a bed with your head turned 45° toward the right ear. 2. Drop quickly to the left side, so that your head touches the bed behind your left ear. Wait 30 seconds. 3. Move head and trunk in a swift movement toward the other side without stopping in the upright position, so that your head comes to rest on the right side of your forehead. Wait again for 30 seconds. 4. Sit up again. This maneuver should be performed three times a day. Repeat this daily until you are free from positional vertigo for 24 hours. (See the video in the supplementary material on the NeurologyWeb site; go to www.neurology.org.)
Statistical analysis.
Statistical analysis included chi-square test for dichotomousvariables and Student’s t-test for continuous variablesfor comparison between treatment groups. Kaplan–Meieranalysis, including log-rank test, was performed to test fordifferences in number of treatment sessions completed untilpositional vertigo resolved. Logistic regression was used formultivariate analysis. Ninety-five percent CIs are presented.A significance level of 0.05 was adopted.
At follow-up evaluation after 1 week, 35 of 37 patients (95%;CI, 81 to 99%) in the MEP group were asymptomatic and showeda negative positional test, whereas in the MSM group, only 19of 33 patients (58%; CI, 39 to 75%) were cured (relative risk,1.64; CI, 1.21 to 2.22). Figure 2 shows the number of treatmentsessions patients performed until they felt relieved from positionalvertigo. The two groups did not differ significantly with respectto treatment-related side effects. Seven of 37 patients (19%;CI, 8 to 35%) in the MEP group and 12 of 33 patients (36%; CI,20 to 55%) in the MSM group performed the maneuver incorrectly(p > 0.05). However, although incorrect performance had noeffect on treatment outcome in the MEP group (p > 0.05),there were significantly more treatment failures in the MSMgroup among patients who performed the maneuver incorrectlycompared with those who made no mistakes (p < 0.05). Themost frequent mistake was a too slow head and body movementin the MSM group (n = 9) and an incorrect head rotation in anyof the head positions in the MEP group (n = 7). Age, sex, andduration of the acute episode of BPPV were not associated withtreatment outcome. Similarly, a logistic regression includingage, sex, positioning maneuver, duration of the acute episode,and accuracy of treatment performance showed that only inaccurateperformance and positioning maneuver were significantly associatedwith outcome.
Figure 2. Kaplan–Meier table showing the percentage of patients who were still symptomatic after 1 week of self-treatment (22 treatment sessions). Significantly more patients were relieved from vertigo and had a negative positional test in the modified Epley procedure group (MEP) compared with the modified Semont maneuver group (MSM).
Our study shows that self-treatment with MEP is more effectiveto abolish PC-BPPV within 1 week compared with self-treatmentwith MSM. Whereas BPPV resolved in 95% of patients who appliedMEP, MSM cured only 58% of patients. The response rate in bothgroups was higher than would have been expected from spontaneousremissions within 1 to 2 weeks reported in previous studies,ranging from 0 to 50%.4,5,8
The efficacy of MEP is comparable with the Epley procedure andthe Semont maneuver, with success rates ranging from 70% aftersingle application to nearly 100% after repeated application.1-5In a comparative study, the Epley procedure and the Semont maneuverwere found to be equally effective with response rates of 90to 95% after one or two applications.9 In view of these results,we considered an untreated control group unjustified from anethical point of view. The rapid resolution of positional vertigowithin a few days in most of our patients after a median durationof 8 weeks argues for a treatment effect and against a spontaneousremission.
In a previous, nonrandomized study, we reported a lower successrate of 64% for self-treatment with MEP (n = 28), which was,however, superior to treatment with Brandt–Daroff exercises10(23% response rate after 1 week; n = 26).6 The Semont maneuveras self-treatment was evaluated for the first time in this study.Although less effective than MEP, MSM successfully relievedhalf of patients from BPPV. Failure of MSM was related to incorrectmaneuver execution. The most frequent mistake was a too slowhead and body movement. During the Semont maneuver, the particlessink to the lowermost point when the patient lies down on theaffected side. When the patient then moves in one swift movementtoward the contralateral side, the particles, because of inertia,do not immediately fall back toward the ampullary end of thePC but may pass its vertex and fall out through its upper openend. If the movement is not performed sufficiently swiftly,the particles, instead of passing the vertex, fall back towardthe cupula. Conversely, incorrect performance of MEP did notadversely affect treatment outcome, indicating that the step-wisepropagation of particles through the PC induced by the MEP ismore robust with respect to minor deviations from treatmentinstructions. Our results confirm that self-treatment may providerapid relief from PC-BPPV and should be considered as complementarytreatment especially for patients who fail to respond to singletherapist-guided positioning maneuvers. It may also be a viabletool for patients with frequent recurrences rendering them independentfrom costly and time-consuming medical care. Because, accordingto our data, MEP is more effective than MSM in relieving BPPV,we recommend MEP as first-line self-treatment approach.
Received August 25, 2003.
Accepted in final form February 17, 2004.
Additional material related to this article can be found onthe Neurology Web site. Go to www.neurology.org and scroll downthe Table of Contents for the July 13 issue to find the titlelink for this article.
Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992; 107: 399–404.[Medline]
Semont A, Freyss G, Vitte E. Curing the BPLS with a liberatory maneuver. Adv Otorhinolaryngol. 1988; 42: 290–293.[Medline]
Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995; 113: 712–720.[Medline]
Asawavichianginda S, Isipradit P, Snidvongs K, Supiyaphun P. Canalith repositioning for benign paroxysmal positional vertigo: a randomized, controlled trial. Ear Nose Throat J. 2000; 79: 732–737.[Medline]
Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. 2000; 75: 695–700.[Abstract]
Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology. 1999; 53: 1358–1360.[Abstract/Free Full Text]
Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952; 61: 987–1016.[Medline]
Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995; 112: 670–675.[Medline]
Massoud EAS, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996; 25: 121–125.[Medline]
Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. 1980; 106: 484–485.[Abstract/Free Full Text]
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